BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusHEMOSTATICS THROMBIN‐JMI SOL 5000UNIT BRAND TIER 99 DETHROMBI‐PAD PAD 3"X3" BRAND TIER 03THROMBOGEN KIT 10000UNT BRAND TIER 99 DETHROMBOGEN SOL 10000UNT BRAND TIER 99 DETHROMBOGEN SOL 1000UNIT BRAND TIER 99 DETRANEXAMIC INJ ACID GENERIC TIER 01 PATRASYLOL INJ 10000/ML BRAND TIER 03ULTRAFOAM MIS 2X6.25X7 BRAND TIER 03ULTRAFOAM MIS 8X12.5X1 BRAND TIER 03ULTRAFOAM MIS 8X12.5X3 BRAND TIER 03ULTRAFOAM MIS 8X25X1 BRAND TIER 03ULTRAFOAM MIS 8X6.25X1 BRAND TIER 03WILATE INJ BRAND TIER 02 PA SPXYNTHA INJ 1000UNIT BRAND TIER 02 PA SPXYNTHA INJ 2000UNIT BRAND TIER 02 PA SPXYNTHA INJ 250UNIT BRAND TIER 02 PA SPXYNTHA INJ 3000UNIT BRAND TIER 02 PA SPXYNTHA INJ 500UNIT BRAND TIER 02 PA SPXYNTHA SOLOF INJ 500UNIT BRAND TIER 02 PA SPXYNTHA SOLOF KIT 250UNIT BRAND TIER 02 PA SPFERRIC SUBSU SOL GENERIC TIER 99 DEHEPARINS ENOXAPARIN INJ 100MG/ML GENERIC TIER 01ENOXAPARIN INJ 120/0.8 GENERIC TIER 01ENOXAPARIN INJ 150MG/ML GENERIC TIER 01ENOXAPARIN INJ 30/0.3ML GENERIC TIER 01ENOXAPARIN INJ 300/3ML GENERIC TIER 01ENOXAPARIN INJ 40/0.4ML GENERIC TIER 01ENOXAPARIN INJ 60/0.6ML GENERIC TIER 01ENOXAPARIN INJ 80/0.8ML GENERIC TIER 01FRAGMIN INJ 10000/ML BRAND TIER 02FRAGMIN INJ 12500UNT BRAND TIER 02FRAGMIN INJ 15000UNT BRAND TIER 02FRAGMIN INJ 18000UNT BRAND TIER 02FRAGMIN INJ 2500/0.2 BRAND TIER 02FRAGMIN INJ 25000/ML BRAND TIER 02FRAGMIN INJ 5000/0.2 BRAND TIER 02FRAGMIN INJ 7500/0.3 BRAND TIER 02HEP FLUSH‐10 INJ 10UNT/ML GENERIC TIER 01HEP SOD/D5W INJ 100/ML GENERIC TIER 01Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion154